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FRAMING HEALTH MATTERS

Interaction of Occupational and Personal Risk Factors


in Workforce Health and Safety
Paul A. Schulte, PhD, Sudha Pandalai, MD, Victoria Wulsin, MD, and HeeKyoung Chun, ScD

effectiveness of health protection and health


Most diseases, injuries, and other health conditions experienced by working
promotion interventions. Specific problem-
people are multifactorial, especially as the workforce ages. Evidence supporting
the role of work and personal risk factors in the health of working people is driven research focuses on a marginal effect
frequently underused in developing interventions. Achieving a longer, healthy that is averaged over the other risk factors in
working life requires a comprehensive preventive approach. To help develop a given context. Such problem-driven re-
such an approach, we evaluated the influence of both occupational and personal search, although beneficial in understanding
risk factors on workforce health. We present 32 examples illustrating 4 combi- a specific risk factor, has led to a lack of
natorial models of occupational hazards and personal risk factors (genetics, age, comprehensive research on the combined role
gender, chronic disease, obesity, smoking, alcohol use, prescription drug use). of PRFs and occupational risk factors (ORFs)
Models that address occupational and personal risk factors and their interactions in work-related illness and injury. ORFs and
can improve our understanding of health hazards and guide research and
PRFs are not only potential confounders or
interventions. (Am J Public Health. 2012;102:434–448. doi:10.2105/AJPH.2011.
effect modifiers of associations of each risk
300249)
factor with disease, but they may also be on
a causal pathway to each other. For example,
Work and workplace hazards are known to THE PROBLEM shift work may be associated with higher rates
compromise the health of workers and repre- of obesity or smoking, or the use of prescrip-
sent a significant national financial, social, Most of the diseases, injuries, and other tion drugs may interact with workplace
medical, and emotional burden, but health is health conditions experienced by working chemical exposures in affecting various organ
also affected by an array of individual risk people are multifactorial. The underlying evi- systems.
factors such as genetics, age, gender, obesity, dence for the role of various risk factors in the To isolate the effects of risk factors, epidemi-
smoking, alcohol use, and the use of prescrip- overall health of working people is frequently ologists usually study them in isolation while
tion drugs.1,2 Despite their awareness of these underused in developing interventions, and assuming that other factors are constant or
hazards, decision-makers and stakeholders do most research focuses on a single risk factor ensuring that they are part of a uniformly
not strongly emphasize taking a holistic view of through the lens of a single discipline or topic. distributed background (and hence they are
the health of working people. For example, an investigator interested in smok- disregarded in terms of interfering with the
Historically, work has been compartmen- ing may treat all other factors as confounders assessment of this single factor). One challenge in
talized from other human activities. This or effect modifiers when assessing smoking--- epidemiological research is to identify major
separation is in part because of legislative disease relationships. Thus, smoking is the modifying factors when they are not uniformly
limitations with respect to worker safety and primary focus, and the overall impact of all risk distributed.6 Determination of effect modification
health and the practice of limiting liability and factors is not directly considered or studied. requires analyses that include interaction terms
determining the cause of injury or illness Similarly, in assessing workplace risk factors, in statistical models or stratification based on
among workers.3 Although some work-related personal risk factors (PRFs) are treated as candidate variables. Identifying effect modifica-
conditions are de facto triggers for compen- confounders or sources of bias, and the com- tion is important because failure to do so can lead
sation in various jurisdictions and the historical plete range of workplace risk factors and PRFs to misinterpretation of exposure---disease rela-
practice has been to take workers ‘‘as is’’ that affect the health of working people are tionships and to inefficiencies, including incorrect
(with existing disabilities and propensities for rarely comprehensively studied. This is partly targeting, in developing interventions.7,8
injury), some compensation and tort systems because society tends to appropriate resources The overarching rationale for considering
apportion the cause of an injury or illness to address certain specific problems such as the interaction of ORFs and PRFs is that the
among various work-related and non-work- smoking, drinking, and occupational disease. health of the contemporary workforce is critical
related causes and compensate only work- Rarely do societal programs focus on research to the well-being of the nation and its interna-
related causes.4,5 However, determining the and interventions addressing the composite tional competitiveness.9---11 The growing burden
extent to which workers’ illnesses or disabilities effect of those risk factors. of illness and injury and the subsequent in-
are influenced by work and nonwork factors is Understanding the interactions between risk creased use of health care services are driving up
not a precise science. factors may help to target and determine the health care costs.12 Ultimately, the impact of

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shortages in skilled labor and rising health care


costs on productivity and profitability can
affect business and national economic health.2
Many developed nations with an aging popula-
tion face the challenge of increasing workforce
participation, especially among older workers.13
As a means of meeting this challenge, govern-
mental policies are being implemented to in-
crease the age of full retirement to balance the
ratio of dependent to employed individuals (the
dependency ratio).14
We address various ways in which ORFs
and PRFs can combine or interact and
develop a conceptual approach to describing
the interaction of these 2 types of risk factors
among workers. The goal is to begin to
develop a theoretical framework for consid-
ering the health of working people in a
comprehensive manner.

THE INITIAL FRAMEWORK

We used 4 basic conceptual models to


evaluate the relationships among ORFs, PRFs, Note. ORF = occupational risk factor; PRF = personal risk factor. Model 1 depicts a model in which the PRF and ORF are
and disease outcomes (including both illness independent of each other with respect to their impact on disease. Models 2, 3, and 4 present a framework in which PRFs
and injury) in working populations. The roles of and ORFs can have interaction effects on disease. In models 2 and 3, PRFs and ORFs affect the same disease or disease
PRFs and ORFs in causing illness and injury stage, whereas in model 4 risk factors can affect different diseases or disease stages that can affect each other or disease
stages that can exacerbate or compound the disease. In some cases, placement of examples in one model versus another
can be very complex. We focus on an initial can change on the basis of scientific information or interpretation of that information. References to disease may also include
framework in which to consider issues associ- injury.
ated with these 2 risk factor categories.
FIGURE 1—Conceptual models delineating PRF and ORF effects.
The models presented here are not meant
to delineate specific molecular-, cellular-, or
organ-level etiological steps; epidemiological LITERATURE SEARCH STRATEGY reviews of studies that tested hypotheses and
mechanisms; or statistical relationships with noted statistically significant effect sizes based
respect to the diseases discussed. Rather, we We employed a 2-stage search strategy for on relative risks or odds ratios.
developed these models to describe theoretical identifying examples of PRFs and ORFs. Ini-
frameworks through which PRFs and ORFs tially, we searched combinations of general THE MODELS
affect health outcomes (Figure 1). They were ORFs, PRFs, and work-related terminology in
adapted from previous work,15,16 specifically the all fields using the PubMed database; the According to model 1 (Figure 1), a PRF and
work of Ottman17 on gene---environment inter- search strategy terminology is listed in Table 1. an ORF can both cause the same disease with
actions. Conceptual models have been used in We then identified articles addressing spe- possibly independent effects. Here we define
epidemiology to represent causal relations cific diseases and disease processes through an independent effect to mean that a given
among factors, to identify potential confounders further investigation of primary sources in level of effect is seen if there is no relationship
or sources of bias, and to categorize effect relevant journal articles and review articles, other than an additive one between the 2 sets
modifiers.18---22 again using all fields in the PubMed database. of factors that cause a particular outcome.23
The 8 PRFs assessed were genetics, age, This next stage of the literature search focused Examples for model 1 may be transitory because
gender, chronic disease, obesity, smoking, on specific hazards and health effects terms further research might suggest that other models
alcohol use, and prescription drug use. We derived from articles identified in the first stage are more suitable.
selected these PRFs because they represent of the search. Models 2 and 3 conceptualize ORFs and
common risk factors for various diseases. They We based the examples used to illustrate PRFs, alternately, as effect-modifying variables
are not meant to be exhaustive but to illustrate each type of model for each PRF examined on that affect a disease association. Thus, in an ORF---
how most PRFs can be assessed with respect studies that were peer-reviewed, original disease association a PRF would be an
to their interaction with ORFs. research articles; meta-analyses; or systematic effect modifier. Conversely, a PRF---disease

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TABLE 1—Initial Search Strategy for Evaluating the Literature on Occupational and Personal Risk Factors for Occupational Illness and Injury

PRF Category Previous 2 Years Previous 5 Years All Yearsa

Genetics Genetics and work


Age Age and work
Gender Gender and work
Chronic disease Stress and work: terms in title only Chronic diseases/conditions and work; stress, Preexisting conditions, occupational exposure, occupational
(preceding 3 y); work-related acute and work; stress, chronic and work diseases and work; preexisting conditions (terms in title/abstract)
diseases, injuries (preceding y only) and workplace terms in title field only
Obesity Exercise, occupational exposure, occupational diseases
and work; physical fitness, occupational exposure,
occupational diseases and work
Smoking Smoking, occupational exposure, Smoking and work: terms in title field only
occupational diseases and work
Alcohol Alcohol and work (title field only)
Prescription drug use Prescription drugs, occupational exposure, occupational diseases
and work; prescription drugs and work: terms in title field only

Note. PRF = personal risk factor. Literature searches for each personal risk factor combined with various occupational risk factors were conducted. Search strategies differed in number of years back
in the literature the search was conducted, and this was dictated by individual characteristics of the PRF or occupational risk factor being searched. General searches refer to search terms that were
not specific to any single PRF.
a
General searches for all years included the following terms: work, work-related, workplace, worksite; workforce, workers; occupation, occupations, occupational; employment, employee; job; health
behaviors and work (title field only); lifestyle and work (title field only); multifactorial etiologies, occupational exposures, occupational diseases and work.

association could be modified by an ORF. Model factors alone may not lead to adverse outcomes; among other factors, as an independent
4 illustrates the situation in which ORFs and however, such factors combined with an occu- risk factor for work-related musculoskeletal
PRFs affect different diseases or disease stages pational risk factor can alter risk. diseases. Factors such as high perceived job
with subsequent interactions between multiple For example, among chemical industry stress and non-work-related stress may be
diseases or disease stages. workers, polymorphism in the NAT2 gene strongly associated with these diseases as
Models 2, 3, and 4 can all contain interaction itself does not cause bladder cancer, but in well.47 In the complex disease process involved
effects of risk factors on outcomes. We define workers with a particular NAT2 genotype, in work-related musculoskeletal diseases, mod-
an interaction effect to mean that a given exposure to aromatic amines increases the eling the effects of age and psychosocial work
magnitude of effect would be observed if there is risk of bladder cancer.33,34,36 Furthermore, factors on disease outcomes (Figure 3) illustrates
a relationship different from an additive one other NAT2 polymorphisms may be protective a way to refine targets for intervention and
between the 2 sets of factors. Although many for bladder cancer in workers exposed to benzi- prevention.
interaction effects may be important in a given dine in the absence of other aryl amine expo- The variable development of occupational
model, not all interaction effects have meaningful sures (such as 2-naphthylamine or 4-aminobi- illness and injury according to age will have
consequences. This concept is important in situ- phenyl), indicating that genetic variations in the implications for disease prevention in an aging
ations in which ORFs and PRFs interact with each same gene can have different effects on a disease workforce. In particular, given the societal
other but such interactions have only minimal outcome according to exposure and mechanism and economic pressures of maintaining work-
effects on disease outcomes. Inclusion of such of action.172 Increasingly, patterns of genes ing populations with larger and larger numbers
interactions may allow more accurate character- within genomes may be associated with various of older workers, understanding the role of age
ization and description of disease mechanisms. PRF and ORF combinations.173,174 in the development of disease and the sub-
For each of the 8 PRFs, 4 models of interaction sequent impact on occupational illness and
with ORFs are identified in Figures 2 through Age injury will be crucial in early disease interven-
9.15,24---164 In the case of each PRF considered, Age is a widely studied effect modifier tion, health promotion, and workplace inter-
these figures present examples with descriptions with a complex biology.175 Age influences ventions for aging workers.
and references for each type of model. people’s susceptibility to disease or dysfunction.
Generally, the incidence of disease increases Gender
Genetics with age, but aging and disease are not syn- Similar to age, gender has often been used to
Inherited genetic factors can contribute to onymous.176 Aging can influence workers’ sus- stratify the workforce into subpopulations with
variable responses of workers to occupational ceptibility or resistance to various hazards. different ORF---disease risk profiles. Despite its
hazards.165---171 In most cases, inherited genetic Becker et al.45 presented data supporting age, importance, epidemiological studies often ignore

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Note. CHD = coronary heart disease; ORF = occupational risk factor; WMSD = work-related musculoskeletal disease. Bidirectional and unidirectional arrows indicate flow of effect in the models
exemplified.
FIGURE 2—Examples of 4 Conceptual Models of the Relationships Between Genetics and Occupational Risk Factors

the impact of gender, although within occupa- and autoimmune disorders (e.g., inflamma- is associated with workplace absenteeism
tions the magnitude of an ORF can vary by tory bowel disease), are undercounted yet and reduced productivity.187---189 Obesity
gender.74,177 Classic occupational epidemiology constitute a significant disease burden in appears to have genetic and environmental
has paid less attention to women’s health issues. the workforce. Coexisting conditions may determinants.190 Lack of physical activity and
Recent studies have begun including gender interact with occupational risk factors.182 high consumption of energy-dense foods are
interactions, but more effort is needed in this Workers are often healthier than the rest of the primary causes of obesity.
regard.178 Rarely have studies taken into account the population, in part because continued Occupational hazards and obesity are part of
the potential interactions between gender, social employment requires good health or the de- a complex matrix of risk factors that are a function
class, employment status, and family roles.179 velopment of disease causes workers to leave of technological development as well as social,
In general, methods have not been systematized employment.183---185 This ‘‘healthy worker effect’’ economic, and demographic factors. Numerous
or used to quantify gender differences in clinical may influence the study of risk factor interac- studies have reported increases in body weight
research.180 tions, with workers having lower rates of among shift workers.15,191 In addition, a relatively
chronic disease than the population at large large number of studies have demonstrated
Chronic Disease has. One US study suggested that, after adjust- the association of job stress with body mass
All individuals enter the workplace with a ment for this effect, the exposure---outcome index.15,192,193 Long work hours have also been
set of characteristics that may affect their vul- association (in this case, the association between associated with higher body mass indexes.191,193
nerability to occupational risk factors. These arsenic and ischemic heart disease) became Obesity has been related to decreased participa-
characteristics may include a broad range of stronger with a statistically significant increasing tion in the workforce and other life activities.194
chronic diseases, many of which vary according trend.186
to the age of the employee (Table 2).181a Some Smoking
chronic diseases, such as hypertension, also Obesity Smoking is an extremely significant deter-
can be risk factors for other diseases such as Obesity is rapidly increasing in most de- minant of adverse health outcomes. It has been
ischemic heart disease. veloped countries. It is a contributing factor shown to be an independent variable, a con-
It is likely that some chronic conditions, in cardiovascular disease, diabetes, asthma, founder, and an effect modifier in occupational
such as skin diseases (e.g., eczema, psoriasis) some cancers, and many other diseases and epidemiological relationships.195---201 Smoking

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Note. ORF = occupational risk factor; WMSD = work-related musculoskeletal disease. Bidirectional and unidirectional arrows indicate flow of effect in the models exemplified.
FIGURE 3—Examples of 4 Conceptual Models of the Relationships Between Age and Occupational Risk Factors

as an exposure is a risk factor for many diseases, Alcohol Use Because of the significant health effects of alcohol
including heart disease and cancer. Alcohol consumption is highly prevalent consumption, loss of workforce members as
In the workplace, shift work has been shown to in many countries and is associated with a result of alcohol use may be another healthy
affect workers’ rates of smoking.196 Other occu- extensive morbidity and mortality.202,203 It has worker effect that influences the understanding
pational risk factors demonstrated to affect been estimated that alcohol misuse contributes of interactions among personal and occupational
smoking rates include work at sea,197 construc- extensively to lost workdays and lost produc- hazards.
tion and cleaning work,198 and work-related tivity.204 Workplace harassment has been
stress.199 Quantification of the role of smoking in reported to lead to alcohol misuse,205 suggesting Prescription Drug Use
occupational health has been difficult but is that occupational hazards can lead to increased Prescription drug use has the potential to
becoming increasingly exact.200,201 Smoking may alcohol consumption. In addition to alcohol interact with ORFs, but detailed knowledge of
also exert a healthy worker effect, with workers consumption as a general risk factor, an esti- its occupational safety and health impact
who have a stronger smoking history and possi- mated 8.9 million workers in the United States remains limited. This interaction also may be
bly shorter work lives affecting the interpretation consume alcohol during the workday and 2.3 related to the widespread presence of pre-
of studies of interactions with ORFs. million do so before beginning the workday.206 scription drug use in developed and developing
societies.207 An aging workforce can be
expected to have an increased need for acute
and chronic pharmacological regimens.207 Pre-
TABLE 2—Common Chronic Diseases or Conditions Present in the Workforce, by Age
scription drug use (the exposure, or PRF) can
Age < 45 Years Age 45–54 Years Age 55–64 Years Age Not Specified thus possibly lead to a range of occupational
outcomes.
Asthma Stress Coronary heart disease Allergies
The PRFs associated with prescription drug
Depression Hypertension Respiratory infections
use may reflect adverse side effects from single
Anxiety Arthritis Migraines/other headaches
medications, interactions between drugs, or
Musculoskeletal pain Bipolar disorder (with depression)
polypharmacy. For example, workplace
Diabetes Hypercholesterolemia (with coronary heart disease)
musculoskeletal trauma can lead to greater
Cancer
consumption of prescription nonsteroidal
Source. Adapted from Munir et al. and Hymel et al.181a,181b anti-inflammatory agents and narcotics,

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Note. ORF = occupational risk factor; WMSD = work-related musculoskeletal disease. Bidirectional and unidirectional arrows indicate flow of effect in the models exemplified.
FIGURE 4—Examples of 4 Conceptual Models of the Relationships Between Gender and Occupational Risk Factors

increasing the risk of adverse side effects from evaluating prescription drugs as PRFs, and future PRFs and ORFs on certain diseases. However,
these drugs.208 research should take this into consideration. other examples used to illustrate model 1
Exposures during the manufacturing and (Figures 2---9), such as the effects of fatigue and
processing of drugs can lead to adverse out- OVERVIEW sedatives on workplace injuries, could easily
comes such as allergy and urticaria.209 An require more complex modeling frameworks as
additional factor for pharmaceutical industry We have described and illustrated 4 con- research provides new insights. This potential-
workers is the impact of concomitant exposures ceptual models for the evaluation of the role of ity underscores the fluidity required in such
to chemicals that can interact with prescribed ORFs and PRFs in the development of disease.
modeling efforts.
drugs. Rates of prescription drug use vary by At an initial stage, a model theorizing an
Models 2 and 3 represent interaction effects
occupation, with high-stress occupations associ- isolated ORF---disease relationship is potentially
(effect modification) of ORFs and PRFs in the
ated with increased use of psychotropic pre- useful in developing interventions in the
etiology of occupational disease. Both of
scription drugs.210 Use of prescription medicine workplace. The seemingly reasonable nature of
these models illustrate effect modification.
can also ameliorate the effects of occupational such a model, however, is perhaps a result
Assessing effect modification may be useful in
risk factors.211 A high-stress job can exacer- mainly of the state of knowledge at a given
at least 3 ways.7,8,21,22 First, understanding effect
bate hypertension, but workers’ use of antihy- point in time. In the case of many diseases, such
modification may define subgroups most in
pertensive medications can result in work per- a rudimentary model is inappropriate because
formance improvements and reductions in the relationship between risk factors and dis- need of intervention. Second, effect modification
absenteeism.212 ease is shown by epidemiological and other may help elucidate how the joint biological
A precondition may lead to both the use of data to be complex. effects of 2 exposures inhibit or enhance
a prescription drug and an adverse outcome, the Model 1 represents independent effects of each other. Third, effect modification may reveal
so-called effect modification by proxy.21 The ORFs and PRFs on outcomes. Some examples different mechanisms. For example, as discussed
drug is not the cause of the adverse outcome but of such effects, such as the roles of genetic in the section on genetics, recent investigations
is a modifier, by proxy, of the effect of interest.213 variants in testicular cancer and the link be- have suggested that certain aromatic amines,
Differentiation of true effect modifiers from ef- tween firefighting and testicular neoplasms, such as benzidine, use genetic pathways for the
fect modifiers by proxy will be a critical issue in highlight the potential independent action of development of cancer that are different from

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Note. COPD = chronic obstructive pulmonary disease; ORF = occupational risk factor. Bidirectional and unidirectional arrows indicate flow of effect in the models exemplified.
FIGURE 5—Examples of 4 Conceptual Models of the Relationships Between Chronic Disease and Occupational Risk Factors

those of other compounds such as 2-naphthyl- model 4 in its basic form, this model can also considered a PRF that is a result of an ORF,
amine and 4-aminobiphenyl. be described in an expanded format, which such as shift work, that in turn can subse-
Model 4 represents more complicated effects enables consideration of more complex quently interact with that same ORF to affect
of ORFs and PRFs on occupational illness relationships between ORFs and PRFs. For another adverse outcome, such as cardiovas-
and injury. Although our examples focus on example, in some contexts, obesity can be cular endpoints. However, presenting examples

Note. ORF = occupational risk factor; WMSD = work-related musculoskeletal disease. Bidirectional and unidirectional arrows indicate flow of effect in the models exemplified.
FIGURE 6—Examples of 4 Conceptual Models of the Relationships Between Obesity and Occupational Risk Factors

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Note. CHD = coronary heart disease; COPD = chronic obstructive pulmonary disease; ORF = occupational risk factor. Bidirectional and unidirectional arrows indicate flow of effect in the
models exemplified.
FIGURE 7—Examples of 4 Conceptual Models of the Relationships Between Smoking and Occupational Risk Factors

of the expanded version of this model and and PRFs on occupational illness and injury is the with a particular PRF, or even the most
discussing in detail various other statistical initial step in the process of defining the causes important from a clinical or public health
analysis issues were beyond the scope of the of illness and injury. In examining mechanisms, perspective, they do illustrate a range of
present work. risk factors, or outcomes, modeling of this nature important health conditions, many with signif-
Future work should explore statistical and represents a theoretical framework for a com- icant societal burdens. Furthermore, these
epidemiological considerations of basic and prehensive approach to the overall health of examples provide a roadmap for melding sci-
complex modeling approaches and issues working people. entific and clinical knowledge that may have
associated with interactive effects. Other areas The bulk of our investigation involved been divided by disciplinary boundaries so that
of investigation should include the role of assessing the scientific literature to obtain we can develop broader models of occupa-
particular statistical approaches in analyzing examples of the relationship of 8 PRFs (genetics, tional illness and injury.
models with PRFs and ORFs, including, but age, gender, chronic disease, obesity, smoking, The placement of an ORF, PRF, and disease
not limited to, the utility of various regressions alcohol use, and prescription drug use) to dis- process grouping in a particular model is also
and other techniques. Assessment of the etio- ease, individually and in relation to work, with subject to the current level of scientific knowl-
logical fraction or relative strength of PRFs and a general focus on epidemiological studies. It edge. This issue is reflected in various models for
ORFs was also beyond the scope of this study. should be noted that, in several cases, applying several of the PRFs presented here, including
selection criteria to articles that might conven- gender and prescription drugs. More research
A Comprehensive Approach tionally be considered disparate but were found evaluating the impact of PRFs on the relation-
From the vantage point of public health in to be relevant to a particular disease process ship of ORFs to occupational disease is needed.
the workplace, different exposures to work- illustrated the potential to link different domains For example, given the extensive acute and
place hazards leading to multiple adverse out- of information to model ORFs, PRFs, and occu- chronic use of pharmacological agents in mod-
comes compound the medical burden on pational disease and develop new hypotheses ern society, there is a need for studying the
individual workers as well as the burden on the for subsequent analyses. impact of this PRF and its role as an independent
workforce as a whole.1 The modeling of Although the examples we identified were or modifying variable, which has significant
independent versus interactive effects of ORFs not necessarily the only possible interactions implications for modern occupational health.

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Note. HBV = hepatitis B virus; ORF = occupational risk factor; VCM = vinyl chloride monomer. Bidirectional and unidirectional arrows indicate flow of effect in the models exemplified.
FIGURE 8—Examples of 4 Conceptual Models of the Relationships Between Alcohol Use and Occupational Risk Factors

In the example of the role of smoking more complex models incorporating multiple stage of such investigations, methodological
and noise in coronary heart disease shown PRFs and ORFs may be more informative in issues regarding direct effects, confounding,
in Figure 7 (model 4), differences in disease identifying high-risk combination scenarios. effect modification, exposure misclassification,
mechanism may exist, with interventions and There is value in considering both ORFs and and conceptualization of the term ‘‘interaction,’’
health promotions varyingly affected. However, PRFs in epidemiological studies. At the design from a statistical as well as a biological

Note. HBV = hepatitis B virus; ORF = occupational risk factor; PRF = personal risk factor. Bidirectional and unidirectional arrows indicate flow of effect in the models exemplified.
FIGURE 9—Examples of 4 Conceptual Models of the Relationships Between Prescription Drug Use and Occupational Risk Factors

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perspective, should be explored, with rationales Workers’ compensation efforts may neces- and interactions of ORFs and PRFs among
and models supported empirically or theoreti- sitate a new category of cause, effect, and risk workers. These examples clearly demonstrate
cally. For example, studies of gene---environ- determination with implications for the use the utility of new representations of PRF---ORF
ment interactions, such as recent explorations of worker’s compensation and health care re- combinations and their impact on our under-
representing environmental exposures with the sources. Ethical, legal, and social issues relevant standing of disease with respect to hypothesis
concept of the ‘‘exposome’’ (a measure of all to long-held beliefs and approaches regarding generation, study design, risk evaluation and
exposures of an individual in a lifetime and disease causation, compensation, blame, and assessment, workplace intervention, clinical
how those exposures relate to disease) and the liability will also need to be considered. In evaluation, and health promotion in working
interaction of such representations with genetic addition, the recent passage of the Patient populations. The models and examples offered
factors evaluated in genomic-wide association Protection and Affordable Care Act, which here highlight the value of conceptual repre-
studies, may suggest future contexts in which to allows employers to offer a health plan pre-
sentations of relationships between ORFs,
further evaluate the nature of interactions mium differential based on employees meeting
PRFs, and disease to drive more fully devel-
between ORFs and PRFs.169,214 standards such as not smoking, reaching rec-
oped approaches to control occupational illness
These methodological considerations are ommended weight levels, and having normal
and injury and develop a comprehensive view
germane not only to occupational epidemio- blood pressure, underscores a variety of ethi-
of workforce health.
logical and other biological study designs but cal, legal, and social issues even as it promotes
Models that combine ORFs and PRFs con-
also to risk evaluation and assessment, inter- the broader use of comprehensive health pro-
tain an inherent flexibility to model greater
ventional paradigms, and health promotion in motion programs in workplaces.218 Nonethe-
disease complexity; can guide various stages of
the workplace. Such design, analysis, interven- less, with an aging workforce and potential
epidemiological investigation, data analysis,
tion, and promotion development requires workforce shortages, there is a need to consider
and intervention development; and possess the
careful consideration of the occurrence, direc- a comprehensive approach to the health of the
capacity to incorporate intricate variables and
tion, and magnitude of effects to optimally workforce and to invest in studying its ramifica-
analyses. Employing models and approaches
judge study designs or data relevant to risk or tions.
that maximize consideration of factors imping-
outcome analyses.215 In addition, collection of Globally, explaining the distribution of
ing on the health of the workforce will allow
PRF data will likely increase the cost of research health and disease exclusively in terms of risk
researchers and practitioners to move beyond
on risk factor interactions. However, a more factors in individuals only partly addresses the
the historically fractionated approach to occu-
thorough appraisal of the health of the workforce health of the workforce. There is a need for
pational illness and injury.
may lead to more effective interventions. contextual or multilevel analyses that address
Thus, a comprehensive approach to the
group- or macro-level variables given that
health of working people can form the basis for
Other Logistical Considerations various economic, social, cultural, and envi-
research and investigation into occupational
Evaluations of ORFs and PRFs in occupa- ronmental group-level characteristics have
illness and injury, address issues important for
tional safety and health research should be been shown to be strongly related to the health
maintaining a healthy workforce despite pres-
reinforced by other logistical considerations. of the workforce.219---223
sures from factors such as aging and unsus-
Occupational factors need to be regularly in- Modeling that considers both PRFs and
tainable dependency ratios, and contribute to
cluded in medical records, particularly as new ORFs would provide a foundation for an
the fostering of an integrated work life to better
electronic record formats are being devel- integrated worklife approach that combines
protect worker safety and health and fortify
oped.216 Clinicians may be able to provide a protection from workplace hazards and health
national and societal well-being. j
more thorough appraisal of a patient’s condition promotion.181b,224---228 This approach could in-
with an occupational history.217 Knowledge of clude, for example, the development of wellness
the interaction of risk factors may foster en- programs at worksites or funded by employers.
About the Authors
hanced management of occupational illness and These types of programs have been demon- Paul A. Schulte, Sudha Pandalai, and HeeKyoung Chun are
injury. Occupational medicine clinicians may strated to result in a positive return on invest- with the National Institute for Occupational Safety and
use information about risk factor interactions ment for both workers and employers.2,12,229,230 Health, Centers for Disease Control and Prevention, Cin-
cinnati, OH. Victoria Wulsin is with SOTENI Interna-
to better address workplace safety and health Nonetheless, attention to PRFs and wellness tional, Cincinnati.
problems, particularly with respect to under- should not be a reason for employers to fail to Correspondence should be sent to Paul A. Schulte, PhD,
standing and addressing health issues arising provide a safe and healthy workplace or to blame National Institute for Occupational Safety and Health,
Centers for Disease Control and Prevention, 4676 Co-
from exposures in the workplace versus those workers for occupational health and safety lumbia Pkwy, MS C-14, Cincinnati, OH 45226 (e-mail:
arising from PRFs. From the perspective of problems.11,15 pschulte@cdc.gov). Reprints can be ordered at http://www.
general medical practitioners, broader informa- ajph.org by clicking the ‘‘Reprints/Eprints’’ link.
This article was accepted April 3, 2011.
tion about PRF and ORF interactions may assist Conclusions
in addressing general health issues in populations We have presented 32 examples of disease
Contributors
in which health prevention and promotion are processes for 8 PRFs and 4 models, demon- P. A. Schulte conceptualized the article and developed
a major focus.217 strating an extensive catalog of combinations the first draft with V. Wulsin. P. A. Schulte and

March 2012, Vol 102, No. 3 | American Journal of Public Health Schulte et al. | Peer Reviewed | Framing Health Matters | 443
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S. Pandalai made various revisions leading to the final management in addressing the nation’s health care crisis. 32. Kellen E, Zeegers M, Paulussen A, et al. Does
article. S. Pandalai helped to reconceptualize the models J Occup Environ Med. 2009;51(1):114---119. occupational exposure to PAHs, diesel and aromatic
and contributed extensively to the figure and tables. 13. van den Berg TIJ, Elders LAM, de Zwart BCH, et al. amines interact with smoking and metabolic genetic
H. Chun contributed to writing early drafts and provided The effects of work-related and individual factors on the polymorphisms to increase the risk on bladder cancer?
input to Figures 2---9. All of the authors participated in Work Ability Index: a systematic review. Occup Environ The Belgian Case Control Study on Bladder Cancer Risk.
the literature review. Med. 2009;66(4):211---220. Cancer Lett. 2007;245(1---2):51---60.

14. Holzmann R. Toward a Reformed and Coordinated 33. Hung RJ, Boffetta P, Brennan P, et al. GST, NAT,
Acknowledgments Pension System in Europe: Rationale and Potential Struc- SULT1A1, CYP1B1 genetic polymorphisms, interactions
We thank the following individuals for comments with environmental exposures and bladder cancer risk in
ture. Washington, DC: World Bank; 2004.
on earlier versions of this article: Benjamin C. Amick III, a high-risk population. Int J Cancer. 2004;110(4):
A. John Bailer, L. Casey Chosewood, William E. Halperin, 15. Schulte PA, Wagner GR, Ostry A, et al. Work,
598---604.
Mary K. Schubauer-Berigan, Christine W. Sofge, Paolo obesity, and occupational safety and health. Am J Public
Health. 2007;97(3):428---436. 34. Golka K, Prior V, Blaszkewicz M, Bolt HM. The
Vineis, Elizabeth Ward, and Naomi Swanson. We also
enhanced bladder cancer susceptibility of NAT2 slow
acknowledge the efforts of Devin Baker, John Lechliter, 16. Schulte PA, Wagner GR, Downes A, Miller DB. A
Sherry Fendinger, Brenda Proffitt, and Vanessa B. acetylators towards aromatic amines: a review consider-
framework for the concurrent consideration of occupa-
Williams regarding logistical issues in preparation of the ing ethnic differences. Toxicol Lett. 2002;128(1---3):
tional hazards and obesity. Ann Occup Hyg. 2008;52(7):
article. 229---241.
555---566.
Note. The findings and conclusions in this article 35. Vineis P, Marinelli D, Autrup H, et al. Current
17. Ottman R. An epidemiologic approach to gene-
are those of the authors and do not necessarily smoking, occupation, N-acetyltransferase-2 and bladder
environment interaction. Genet Epidemiol. 1990;7(3):
represent the views of the National Institute for Occupa- cancer: a pooled analysis of genotype-based studies.
177---185.
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